Critique your article of choice using the
Research Critique Rubric
and following components:
- Identification of the research question/problem/hypothesis.
- Identification of topics explored in review of literature.
- Identification/definition of research methodology and design
- Description of subjects/participants in the study.
- Exploration of ethical issues and protection of human subjects.
- Data analysis.
- Discussion of findings.
- Use of additional sources from nursing journals.
- APA style (title page, abstract, citations and reference page).
- Demonstration of professional grammar and organization.
- The critique should be a scholarly written paper to include a 3-5 typewritten pages in length, excluding the title page, abstract, and reference page.
- Papers must be submitted in APA format with any direct quotes.
- Complete the critique with the use of outside references that adequately critique your article. An example of a valid outside reference would include your course text.
Review and use the Research Critique Rubric to critique your article.
evidence based practicenursing research
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Abstract
Full Text
AIM The purpose of this study was to examine, on a national level, nursing students’ perceptions after
experiencing a patient death. BACKGROUND Death is a highly stressful experience for nursing students.
Debriefing, which routinely occurs with a patient’s demise in the simulation setting, typically does not happen in
actual death situations. METHOD A mixed-methods design using quantitative and qualitative questions as part
of an anonymous survey was sent to the membership of the National Student Nurses’ Association. Of
approximately 55,000 members, 2,480 responded to the survey. RESULTS Experiencing a patient death as a
student occurred for 41 percent of participants in the nationally representative sample. Of those who
experienced a patient death, 64 percent did not receive any debriefing. CONCLUSION Most nursing students did
not feel prepared to care for a dying patient and the patient’s family. Students need and want more education on
Headnote
Abstract
AIM The purpose of this study was to examine, on a national level, nursing students’ perceptions after
experiencing a patient death.
BACKGROUND Death is a highly stressful experience for nursing students. Debriefing, which routinely occurs
with a patient’s demise in the simulation setting, typically does not happen in actual death situations.
METHOD A mixed-methods design using quantitative and qualitative questions as part of an anonymous survey
was sent to the membership of the National Student Nurses’ Association. Of approximately 55,000 members,
2,480 responded to the survey.
RESULTS Experiencing a patient death as a student occurred for 41 percent of participants in the nationally
representative sample. Of those who experienced a patient death, 64 percent did not receive any debriefing.
CONCLUSION Most nursing students did not feel prepared to care for a dying patient and the patient’s family.
Students need and want more education on end-of-life nursing care.
My Patient Died: A National Study of Nursing
Students’ Perceptions After Experiencing a Patient
Death
Heise, Barbara A; Wing, Debra K; Hullinger, Amy H R.
Nursing Education Perspectives; New York Vol. 39, Iss. 6, (Nov/Dec 2018): 355-
359.
DOI:10.1097/01.NEP.0000000000000335
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KEYWORDS Death Education – Debriefing – Nursing Education – Nursing Students – Death Education – Debriefing
Most nurses experience patient death during the course of their careers. The nurse is the primary health care
provider involved in caring for patients and their families at the endof-life (EOL) and throughout the dying
process, including postmortem care (Bryant, 2008). Nurses promote a “good death” by providing physical,
emotional, and spiritual care while also advocating for the cultural preferences of dying patients and their
families.
Death is an emotionally charged issue for anyone. For registered nurses, death is also a high-stress situation
(Leighton & Dubas, 2009; Zheng, Lee, & Bloomer, 2016), with most experienced nurses able to vividly recall their
first death of a patient (Anderson, Kent, & Owens, 2015; Kent, Anderson, & Owens, 2012). For nursing students
who are just learning the RN role and responsibilities, the death of a patient is often a foreign, frightening, and
overwhelming experience that may have long-term effects on their professional and personal lives (Kent etal.,
2012).
LITERATURE REVIEW
Patient death is a commonly reported source of stress and anxiety for nursing students (Allchin, 2006; Carson,
2010; Edo-Gual, TomásSábado, Bardallo-Porras, & Monforte-Royo, 2014; Gallagher et al., 2014; Parry, 2011; Zheng
et al., 2016). Nursing students’ reactions to their first patient death often include negative emotions, such as fear,
sadness, frustration, anxiety, helplessness, and guilt (Neiderriter, 2009; Parry, 2011; Poultney, Berridge, & Malkin,
2013; Zheng et al., 2016). Although many students experience a patient death during their education, few feel
adequately prepared to interact with a dying patient and his or her family in the clinical setting and to cope with
the experience (Gallagher et al., 2014; Zheng et al., 2016). Current nursing education is generally considered
inadequate to prepare nursing students for EOL care (Cavaye & Watts, 2012; Gillan, van der Riet, & Jeong, 2014;
Kent et al., 2012; Schlairet, 2009; Wallace et al., 2009). After their first death experiences, students frequently
state that they were not ready to provide EOL care, expressed difficulty communicating with the dying patient or
family, and did not receive sufficient support from clinical instructors and staff. Nursing students reported
increased stress and anxiety due to feelings of inadequacy and lack of preparation (Cavaye & Watts, 2012; Dos
Santos & Bueno, 2011; Gallagher et al., 2014; Huang, Chang, Sun, & Ma, 2010; Parry, 2011; Zheng et al., 2016).
Nursing students who had positive first death experiences indicated that helpful factors included a supportive
clinical instructor or staff member, role modeling, and postclinical debriefing (Carson, 2010; Gallagher et al.,
2014; Huang et al., 2010). Debriefing is commonly included in simulated EOL training but often does not occur in
the clinical setting (Thompson, 2005). The opportunity to discuss the death experience with an instructor may
help nursing students cope with the experience and increase competence and confidence for future care of dying
patients.
Nursing students must receive adequate preparation and support to provide quality EOL care in the clinical
setting and be equipped to cope with patient death. Most studies on nursing students and their experience with
patient death have involved small samples of nursing students. This survey is the first to examine nursing
students’ perceptions of their first experiences with patient death on a national level. By understanding students’
experiences and the need for suitable preparation, support, and debriefing, nurse educators may be better able to
guide nursing students through their first experiences with EOL care and patient death.
THEORETICAL FRAMEWORK
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Benner’s (1982) seminal work, From Novice to Expert, delineates five levels of nursing proficiency. Although
Benner’s theory of nursing did not include nursing students, her delineation provides insight on a prelicensure
nursing student who could be classified at a prenovice level. Level 1 is the novice RN who has no experience in
clinical situations such as EOL care. At this level, the novice nurse does not have the discretionary judgment to
determine which parts of the situation are most relevant. The novice nurse feels most comfortable with objective
tasks, such as taking vital signs, rather than a more advanced skill of helping the dying patient and family to
cope. Level 2 is the advanced beginner who has marginally acceptable performance. Nurses at Levels 1 and 2
need mentoring by expert nurses.
At Level 3, the competent nurse has been providing EOL care for approximately two to three years. Typically, this
nurse provides conscious, deliberate planning to achieve efficiency and organization, and no mentoring is
needed. However, the competent nurse is still unable to recognize which parts of the EOL situation are most
important.
At Level 4, the proficient nurse is able to see EOL care for the dying patient and the family as a whole. This nurse
knows what to typically expect during EOL care and can modify the plan as needed.
Finally, at Level 5, the nurse is an expert who intuitively hones in on salient issues. Expert nurses have a deep
understanding of EOL care and the many ways that dying patients and their families approach death. They offer
many ways to understand, cope, and accept the final phase of life, which, for most people, is a totally uncharted
passage. Expert nurses in EOL care often stay in this field because they feel they can coach patients and families
through a very difficult and often not discussed part of life.
Nursing students do not have the experience to perform the advanced roles of an expert nurse caring for the
dying person and family. Along with competent clinical skills, expert nursing skills required during EOL care
include advanced communication skills to determine patient preferences, advocacy for patient and family to
promote dignity, advanced pain management skills, comprehensive supportive care to the patient and family to
alleviate suffering, constant assessment to ensure interventions are congruent with patient wishes, and
promoting the dying patient’s autonomy and right to self-determination.
Some nursing students have previously experienced the death of a family member. However, the death of a
patient is different and may require a level of responsibility that was not present for the family member. In
addition, caring for someone who is dying, as well as caring for the dying patient’s family, requires advanced
clinical skills that a nursing student does not yet possess.
METHOD
A cross-sectional descriptive survey design was used for this study. Following approval from the university
institutional review board and National Student Nurses’ Association administration, nursing student members of
National Student Nurses’ Association (approximately 55,000 members) were emailed a brief description of the
research project and an invitation to participate with a link to the online questionnaire. An implied consent form
was available to be viewed by participants before beginning the survey. Participant responses were collected
using Qualtrics online survey software.
Participants were asked to answer six demographic questions and 14 survey questions about their experience
regarding a patient death during their time as a nursing student. Two open-ended questions asked participants
to describe their experience and indicate what they would have liked to be taught regarding EOL care of a patient.>
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Estimated time commitment for participants was 15 to 20 minutes. This article reports the results of the
quantitative questions in the survey.
After the response period had ended, quantitative data were downloaded from Qualtrics to SPSS version 22 (IBM
Corp., 2013). Quantitative data were reviewed for missing values and outliers before further analysis using
appropriate descriptive statistics and plots. Descriptive statistics for demographic variables and survey
questions were calculated. Chi-square test of association was used to examine relationships of selected
categorical variables.
RESULTS
Descriptive statistics for demographic characteristics of the participants are reported in table form in Table 1.
Sample
A total of 2,804 individuals responded to the invitation to participate and started the survey. A total of 2,480 (88.4
percent) completed the survey. Most respondents (80 percent) were female, half were under age 27, and the
majority were white (67.6 percent). A majority of the respondents (60.7 percent) reported being single, and about
a quarter (26.8 percent) reported being married. Most (57.6 percent) of the students said they were in bachelor’s
programs; about a quarter (25.9 percent) reported being in associates programs. Participants came from every
state in the United States as well as the District of Columbia with more populous states (e.g., CA, FL, NY, PA, and
TX) proportionally represented in the sample.
Descriptive statistics for questionnaire items are reported in Table 2. A majority (65.8 percent) of respondents
reported being present at a death outside of their nursing experience; almost 41 percent reported being present
at a death as a nursing student. The majority of those who experienced a patient death (62 percent) experienced
that death early in their nursing programs.
Responses for Students Who Experienced a Death
The remaining questions were directed specifically toward those who reported experiencing a patient death as a
student (n = 1,148). Slightly more than a quarter of those respondents (26.8 percent) said they needed help
coping. Only one third of these students received debriefing.
A chi-square test of association was used to examine the relationship between reporting the need for help
coping with a patient death and receiving debriefing. Of the 1,148 students respondents, 33 (2.6 percent) had
missing data and were excluded from the test. The test was not significant, x2(df = 1, n = 1,115) = 1.19, p = .275,
indicating that there did not seem to be an association between needing help coping and receiving debriefing
after experiencing a patient death as a student. A majority (194/306, 63.4 percent) of those who reported
needing help coping did not receive debriefing.
Participants were asked to rate their level of preparation on a scale of 1 to 4 (1 = prepared, 2 = somewhat
prepared, 3 = prepared, 4 = very prepared) in several areas related to death and dying: process of death and dying,
EOL care, and ways to cope with the death of a patient.
* Thirty-six percent of nursing students asked if they felt prepared with the process of death and dying reported
they were less than prepared (not prepared or somewhat prepared). >
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* Perceptions of being prepared to provide EOL care resulted in 45 percent feeling less than prepared (not
prepared or somewhat prepared) and 47 percent felt prepared or very prepared.
* Asked if they felt prepared to cope with the death of a patient, most nursing students (45 percent vs. 35
percent) felt less than prepared (unprepared or somewhat prepared).
Only 24 percent of the nursing students reported that their nursing curriculum (what they learned in class)
prepared them in general EOL care. Only 17 percent felt that the curriculum prepared them to cope with the death
of a patient. Participants were asked who helped them prepare to deal with issues surrounding patient death
(process of death and dying, EOL care, and ways to cope with death of a patient); options for each category were
as follows: no one, clinical instructor, clinical staff, other nursing students, friend or family member, and learned
in nursing class. Learned in nursing class and clinical instructor were among the top-ranked answers in most
categories. The top answer to who prepared respondents to cope with the death of a patient was “no one.”
Clinical instructors were referred to as preparation resources for EOL care (19 percent), process of death and
dying (17 percent), and coping (17 percent) in these areas.
Participants were asked to rate their level of preparation on a scale of 1 to 4 (1 = unprepared, 2 = somewhat
prepared, 3 = prepared, 4 = very prepared) in several areas related to communication: communication with dying
patient, communication with patient’s family, and communication with members of the health care team. The
majority (57 percent) of nursing students felt less than prepared (unprepared or somewhat prepared) to
communicate with a dying patient; only 23 percent reported feeling prepared or very prepared. Again, the majority
(64 percent) of participants felt unprepared or somewhat prepared to communicate with the dying patient’s
family. However, participants felt more prepared to communicate with members of the health care team (45
percent vs. 35 percent).
Participants were asked who helped them prepare to deal with issues surrounding communication
(communication with dying patient, communication with patient’s family, and communication with members of
health care team); options for each category were as follows: no one, clinical instructor, clinical staff, other
nursing students, friend or family member, and learned in nursing class. The top answer to who prepared
respondents for all the communication questions was “no one.” Students responded that their curriculum
prepared them to communicate only 18 percent of the time when communicating with the dying patient, 20
percent of the time when communicating with the family of a dying patient, and 18 percent of the time when
communicating with the health care team. Clinical instructors helped prepare students to communicate with the
dying patient (15 percent), the family of the dying patient (14 percent), and the health care team (18 percent) of
the time.
Nursing students were asked specifically about what they would like to be taught about EOL care. The number
one answer from students was more education on how to communicate with the dying patient and family.
Students wanted more education on EOL care in general, including the actively dying process and supportive
resources for the family and the patient. Students also wanted education on postmortem care of the patient.
Students requested debriefing and education on how to cope with a patient death. They suggested more
education on EOL care earlier in the nursing curriculum with more educational activities involving death and
dying through simulation scenarios, faculty experiences, and even a hospice clinical.
DISCUSSION
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It is significant to note that the sample was fairly representative of nurses in the United States, both in terms of
geography and in terms of race. Participants came from every state and the District of Columbia. Nearly one third
(31.9 percent) identified with racial groups other than Caucasian.
Nationally, nursing students (41 percent) reported being present at a patient death. This high percentage of
individuals who experience a patient death as a student highlights the importance of death education. Despite
the sensitive nature of the topic of death itself, nurses need to be prepared for the almost inevitable death
experiences they will encounter. Current recommendations strongly encourage nursing schools to educate
students about EOL care (Ferrell, Malloy, Mazanec, & Virani, 2016). Death education may be integrated into
nursing curricula, particularly for concept-based nursing programs.
More work needs to be done to help students cope with patient death. Asked who helped them cope with the
death of a patient, the top answer was “no one.” Clinical instructors were reported to play a leading role in the
training of nursing students in all areas regarding death and dying. Given that clinical instructors are frequently
adjunct faculty who receive lower levels of professional development than regular faculty in the academic
setting, it is possible that many clinical instructors are insufficiently prepared to guide students in matters of
death and dying, communication with family and medical staff, and debriefing. Clinical instructors spend more
one-on-one time with students than almost any other instructor in nursing school. They are also uniquely
positioned to observe student interactions with patients and patients’ families.
The Institute of Medicine (2015) publication Dying in America specifically identifies a lack of communication
skills, interprofessional education, and curricula focused on palliative and EOL care in nursing education. The
American Association of Colleges of Nursing (2016) recommends competencies and curricular guidelines
regarding EOL issues, including communication with dying patients and families and assisting the patient, family,
colleagues, and one’s self to cope with the dying process, grief, and bereavement. Role modeling, simulation, and
debriefing may be the most efficacious ways to prepare students to deal with the challenges associated with
patient death (Keene, Hutton, Hall, & Rushton, 2010). In addition, introducing students to critical reflective
practice early in their academic endeavors may increase their resilience while creating cultural meaning for the
dying process (Hodges, Keely, & Grier, 2005). As Benner (1982) noted, novice nurses (and we would add prenovice
nurses) need mentoring, particularly in the advanced skills needed for EOL care.
LIMITATIONS
It may be noted that a sizeable proportion (11.6 percent) of those who began the survey did not complete it. It
may also be noted that many of the questions directed to those who experienced a patient death as a student (n
= 1,148) had high rates of missing data (around 20 percent). Patterns of missing data for those questions were
examined. Most individuals completed all of the questions (n = 902, 78.6 percent). It was found that a large
majority of missing answers were attributed to a consistent set of individuals (n = 224, 19.5 percent), who, it
seems, simply did not complete most of the questions. A small percentage of individuals (n = 22, 1.9 percent)
chose not to answer between one and six questions but completed the others.
Although it is not possible to determine specific reasons for noncompletion, it may be possible to speculate. The
topic of experiencing a patient death during schooling has the potential to be emotionally difficult to think about
and discuss. It may be that the emotionally difficult nature of the topic led some individuals to not complete the
questions. This survey also asked several open-ended questions in the format of typed responses. It may be that
additional time required to think about and formulate responses led some individuals to give up rather than
complete the entire survey.
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IMPLICATIONS FOR NURSING EDUCATION
Students need and want more education on EOL nursing care as well as how to communicate with dying patients
and their families and postmortem care. Most nurses, at some point in their careers, will encounter a patient who
is dying. Although death is often not discussed in many societies, it is a conversation that needs to be held in
order to ensure that the dying patient’s wishes are known.
The Conversation Project (http://theconversationproject.org), which is dedicated to helping individuals talk
about their EOL issues, gives individuals the words to say to family members and to health care providers to start
the conversation on what they would like at EOL. Nurses provide the majority of care and are uniquely positioned
to help start the conversation of patient preferences and assist the patient and family through the dying process.
Dying is a deeply personal experience. For nursing students, the death of a patient, at the very beginning of their
career path, is often a stressful and overwhelming experience. Although debriefing and mentoring take place
routinely in simulation, they do not happen most of the time in real life. It is a double-edged sword to tell novice
nurses to care about their patients while asking those same nursing students to turn off caring when the patient
is dying or has died. Experienced nurses do a disservice to novice nurses when they tell them to “toughen up,”
rather than discuss their views of the dying experience. This lack of discussion and acknowledgement of salient
issues during the dying process may lead to nurse burnout and compassion fatigue.
In the clinical setting, nurse educators, particularly adjunct clinical faculty, need to be trained in debriefing
techniques, critical reflection, and mentoring nursing students as they provide care for those in the last phase of
life. Students need to be exposed to the dying experience, but with expert nurse mentors to role model and guide
them through an often challenging situation (Österlind et al., 2016).
For nursing students, as suggested by the respondents to this study, more simulation experiences with patient
demise and debriefing need to be part of the nursing curriculum. Allen (2018) points out that, even in an EOL
simulation setting, nursing students caring for dying patients experience increased stress. In our study, students
requested more EOL experiences through simulation and through clinical experiences, such as hospice and
palliative care with mentoring from their nursing faculty.
Sidebar
The authors have declared no conflict of interest.
Copyright © 2018 National League for Nursing
doi: 10.1097/01.NEP.0000000000000335
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6/17/2019 My Patient Died: A National Study of Nursing Students’ Perceptions After Experiencing a Patient Death – ProQuest
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Research Critique Rubric
Criterion |
Description of Criterion |
Not Submitted 0% |
Not Met 50% |
Met 75% |
Exceeds 100% |
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Identification of the research question/problem/hypothesis
10% |
This area should cover a review of the introduction of the article. What do the authors state is the importance of the study and why is it being conducted? What is the authors’ purpose or intention for the study? What questions or hypothesis do the authors aim to answer? |
No posts submitted. |
The description is not provided. |
The description does not address all of the given points, or the description of any point is not supported by the article. |
The description addresses all of the given points, or the description of any point is not supported by the article. |
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Identification of topics explored in review of literature 10% |
How did the researchers identify a gap in the science? What literature did the authors review prior to starting the study? How does the literature review contribute to the research design? This may or may not have a separate section in the article itself, but it can be determined by information provided in the article. |
The description does not address all of the given points, or the description of any point is not supported by the article. |
The description addresses all of the given points, or the description of any point is not supported by the article. | |||||||||||||||||||
Identification/definition of research methodology and design 10% |
How was the study conducted? Why was this method selected for the research, and how was the study was conducted. Was this this most appropriate method for this study? |
The description is not provided. | The description does not address all of the given points, or the description of any point is not supported by the article. | |||||||||||||||||||
Description of subjects/participants in the study 10% |
Who were the study participants? Was the group or population of interest adequately described? Were the setting and sample described in sufficient detail? Was the best possible method of sampling used to enhance information richness and address the needs of the study? Was the sample size adequate? |
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Exploration of ethical issues and protection of human subjects 10% |
Explain how the protection of human subjects and cultural considerations were addressed by the researcher, using specific information from the journal article. |
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Data Analysis 10% |
How did the researchers analyze the data? What statistical tests or other methods of interpretation were used to analyze the data? Was the data analysis strategy compatible with the research tradition and with the nature and type of data gathered? Did the analysis yield an appropriate “product” (e.g., a theory, taxonomy, thematic pattern, etc.)? Did the analytic procedures suggest the possibility of biases? |
The description is not provided. | ||||||||||||||||||||
Discussion of findings 10% |
How effectively does the researcher answer the posed research question/problem/hypothesis? What are strengths and limitations of the study? Do the study findings appear to be trustworthy—do you have confidence in the truth value of the results? How might the findings be applied to practice? |
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Use of additional sources from nursing journals 10% |
At least two sources from nursing journals (or one nursing journal and one from the text) are used in addition to the article that was critiqued. |
No additional journals/text were used and cited, or the journals used are not nursing journals. |
Only one additional source (either nursing journal or text) is used and cited. |
At least two additional nursing journals (or one journal & one text) are used and cited in the paper. |
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APA style 10% |
Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized. A title page, abstract and reference page are included. |
The submission does not include in-text citations and references according to APA style for content that is quoted, paraphrased, or summarized. |
The submission includes in-text citations and references for content that is quoted, paraphrased, or summarized but does not demonstrate a consistent application of APA style. |
The submission includes in-text citations and references for content that is quoted, paraphrased, or summarized and demonstrates a consistent application of APA style. |
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Grammar and Organization 10% |
Demonstrate professional grammar and organization in the content and presentation of your submission. |
No posts submitted. |
Content is unstructured, is disjointed, or contains pervasive errors in mechanics, usage, or grammar. |
Content is poorly organized, is difficult to follow, or contains errors in mechanics, usage, or grammar that cause confusion. |
Content reflects attention to detail and is organized. Mechanics, usage, and grammar promote accurate interpretation and understanding. |
Version 1
NG309 Evidence Based Practice
August 2019